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Session 284, February 14, 2019 4-5 pm
Jennifer Waterbury, MSIE, CSSBB, Senior Bundled Payment Engineer, AdventHealth
Mark Hiller, Vice President of Bundled Payment Collaborative & Analytics, Premier Inc.
Navigating Multi-Hospital, Episode-Based Care Delivery
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Jennifer Waterbury, Senior Bundled Payment Engineer,
AdventHealth
Mark Hiller, Vice President of Bundled Payment Collaborative
& Analytics, Premier Inc.
Conflict of Interest
Have no real or apparent conflicts of interest to report.
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Review Episode-Based Models and Analytics
Collaboration & Data
Refacing of BPIP Interface Data
Internal Analytics Tool
Outcomes
Future Applications
Agenda
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Assess episode-based care delivery modeling for a total joint
bundled payment program
Identify analytics capabilities, education, training and process
improvements needed across multi-hospital teams
Discuss claims analytics data optimization for bundled
payment program
Recognize challenges with limited data that led to development of
a real-time internal bundled payment analytic tool
Restate the benefit of standardized data and analytical support
for a multi-hospital organization to achieve success with
bundled payments
Learning Objectives
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Different Types of Data
Blinding of Information Varies by Payer and Even Type of Contract Paid Amounts, Provider
Blinding Challenges
No Standard Reliable Format to Payer Claims Files Mapping Necessary for Each New Program
File Timing and Format Changes Inconsistent
Federal Program Files Usually Most Transparent Ideal Starting Files
Claims-based Information May Differ from EHR/HIE Sourced Data e.g. Mammogram Rate
Claims Lag Balance “Complete” with “Timely”
Cost Information From Outside May Need to be “Siloed”
Different Set of Skills/Expertise
Management of Changing or Absent Attribution in Populations
Creation of Actionable Information from Overwhelming Data – “Bigger Haystack”
Claims Analytics Challenges
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Awards
2017 Bundled Payment Collaborative Member Awards
Bundled Payment Intelligence Platform Super User Award
Member Sharing Masters Award
2018 Healthcare Informatics
Innovator Award 2
nd
Place
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Episode-Based Models
Comprehensive Care
for Joint Replacement
(CJR)
Bundled Payments for
Care Improvement
(BPCI) Advanced
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Episode-based Care/Payment includes:
Full continuum of care from episode start through care transitions
Incentives for improving efficiency and care coordination
Clinical Outcomes
Financial Accountability
Episode-Based Analytics
Anchor
Hospitalization
(Episode
Initiator)
Anchor
Hospitalization
(Episode
Initiator)
Physician Fee
Schedule
Physician Fee
Schedule
SNF/IRF/LTCHSNF/IRF/LTCH
Home Health/
Outpatient
Services
Home Health/
Outpatient
Services
ReadmissionsReadmissions
90 days
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Comprehensive Care for
Joint Replacement
CJR: mandated model for Medicare hip & knee replacements
Started April 2016 and continues through December 2020
Episode: Anchor Admission through 90 days post discharge
Target & Actual spend includes all costs (some exclusions apply)
Reconciliation/Repayment
Revised Dec 2017 reducing mandated Metropolitan
Statistical Areas
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Original rule: 16 hospitals within 4 states
No prior orthopedic bundled payment experience
Joint Programs at some facilities
Corporate Support and Standardization needed
Engage with physicians, executives
Care Coordinators, Program Managers
Timely comprehensive data
CJR and AHS
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Data Challenges
AHS Internal Dashboard Limitations for THA/TKA
Only displayed 30-day readmissions
Not tracking complication rate
Not tracking post-acute care
CMS data over a year old
3 years combined
Multiple baseline files
Not user friendly
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Medicare Claims Data Challenges
IPHDR File
EPI File
Have to link from IPHDR to EPI by EPI_ID
Look at the Anchor_OP_NPI to determine the physician
Must have a NPI list with physician names
For patient name: use BENE_SK and BENE_HIC_Num in the DENOM file
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Overwhelming!!!
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Additional Issues
Download of multiple files with each publication
Incomplete due to Claims Lag
Medicare data only published quarterly (originally)
Now monthly
Quality metrics not included
Medicare Claims Data Challenges
How do we know in real-time how we are performing?
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Collaboration and Data
AHS joined Premier’s Bundled Payment Collaborative Sept. 1, 2015
Collaborative provided access to the Bundled Payment Intelligence Platform
(BPIP)
Bundled payment specific cross continuum claims analytics for CJR
Became available and trained users in June 2016
Additional efforts:
Bi-weekly Project Status meetings to review the progress of the Comprehensive
Care for Joint Replacement (CJR) program
Attendance at AHS Steering Committee meetings
Gainsharing Analytics Platform (GSAP)
AHS team serves as one of the leading examples of success for other
members of the collaborative
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CJR Reporting Interface
User Friendly By Hospital and By Physician Claims Data
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CJR Reporting Interface
This allowed us to not
have to struggle with the
Medicare claims files
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AdventHealth CJR Financials
Performance
year 2
Performance
year 2
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AdventHealth CJR Post-Acute Care
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AdventHealth CJR Patient Tracking
Dashboard
Dashboard to display near real time data for key metrics:
Calculator for predicting episode total spend, depending
upon patient type and PAC services utilized
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Electronic Medical Record (EMR)
Data team member(s) with understanding of multifaceted
layers of CJR
Access to advanced data analytic tools and developer
Collaborative Team
Engaged Hospital CJR Program Owners
Prerequisites
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Approval from Steering Committee
Collaborated with leadership and CJR sites to identify key metrics
Identify sources for data using EMR whenever possible
Mirror criteria and timeframes from CJR Regulations and
Quality Metric specifications
Weekly meetings with the analytics team
Enhanced analytic team’s knowledge through a CJR site visit
Piloted to hospitals for feedback prior to production
Continue collaboration with analytics team for further
enhancements
Development Process
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Executive Summary
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Patient Details
Drill down to patient specific data combined
from EMR and manually submission
Care Navigator data to capture readmissions
to facilities outside of AHS
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Beneficiary Letter
Presence of scanned in
Beneficiary Letter
captured in EMR
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Complications
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Care Coordinator Data
Collected and submitted by each hospital’s
CJR Care Coordinator
Uploaded to secure FTP site for the
dashboard to easily access
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Cost Prediction Calculator
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CJR Patient Tracking Dashboard
Go-Live
Early 2017 (PY2)
Data is refreshed daily
Continual training and ad hoc phone calls
Share standardized data at meetings
How does this benefit a multihospital organization?
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THA/TKA Complications
Dashboard provides up to date knowledge, instead of 2 years
behind
Developed a Performance Improvement Project
Identified opportunity with pneumonia complications and a
correlation with higher BMI
Strengthening system for patient optimization
Raw Complication within AHS facilities only
PY 2 (FY): 3.2%
PY 3 to date (~6-8 months): 1.5%
Received reconciliation payment for PY 1 and PY 2
PY 1 & PY 2 Quality was in “Good” category and are aiming for “Excellent”
Hospital A
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Return to Hospital
Dashboard provides up to date ED visits, Observation statuses, and
Readmissions to our own facilities
Analyzed the reasons for return visits to see if there was
consistency and identified constipation
Identified opportunity in education
Beefed up pre-op class
Going through the over the counter medications
Raw readmissions to AHS facilities
2017 discharges: 18%
April-July 2018 discharges: <10%
Received reconciliation payment for PY 1 and PY 2
PY 1 and PY 2 quality score categories are “Good”
Hospital B
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Use dashboard to estimate the potential costs/spend of patient while
keeping the best outcomes in mind
Optimize post-acute care placement
Raw Complication within AHS facilities only | Total Claims
470 without fracture
PY 1: 5.9% | $23,156
PY 2: 0% | $22,110
Received reconciliation payment for PY 1, projecting reconciliation
payment for PY 2
PY 1 Quality was in “Acceptable” category
Hospital C
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PY2
Reconciliation payment was an excess of $1.8M
All 12 CCNs received reconciliation
Quality
4: Excellent 6: Good 2: Acceptable
PY1 compared to PY2 (6 months of each)
13-17% decrease in acute hospital LOS
19% decrease in 90-day readmissions
17% decrease in SNF discharges
Bi-Monthly calls to review performance
including data
AdventHealth CJR Outcomes
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Success, but Still Improving
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BPCI-Advanced
CMS released on January 9
th
, 2018
Voluntary model
29 inpatient and 3 outpatient clinical
episodes
CJR takes precedence
Hierarchy: Attending, Operating,
then Hospital
Effective Oct 1, 2018 through
December 31, 2023
90 day post discharge episodes
(like CJR)
20% stop loss/stop gain out the gate
(not like CJR)
Quality metrics
All-cause Hospital Readmission
Measure (NQF #1789)
Advanced Care Plan (NQF #0326)
Perioperative Care: Selection of
Prophylactic Antibiotic: First or Second
Generation Cephalosporin
(NQF #0268)
Hospital-Level Risk-Standardized
Complication Rate (RSCR) Following
Elective Primary Total Hip Arthroplasty
(THA) and/or Total Knee Arthroplasty
(TKA) (NQF #1550)
Hospital 30-Day, All-Cause, Risk-
Standardized Mortality Rate (RSMR)
Following Coronary Artery Bypass
Graft Surgery (NQF #2558)
Excess Days in Acute Care after
Hospitalization for Acute Myocardial
Infraction (NQF #2881)
ARRQ Patient Safety Indicators
(PSI 90)
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Challenges: Data complexity and lag
Automate data from EMR, as much as possible
Standardized, actionable, near-real time CJR dashboard has
benefited our sites
Involve clinical end-users to identify key metrics
Build strong analytics team
Site visit with data analytics team
Validation and ongoing refinement
Beta-testing to identify glitches and make adjustments
Sharing best practices through a continual feedback loop
Decreased complications and readmissions
Collaboration across the system
Summary
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Jennifer Waterbury, MSIE, CSSBB
Sr. Bundled Payment Engineer
AdventHealth
407-357-3079
Jennifer.Waterbury@AdventHealth.com
Mark Hiller
Vice President of Bundled Payment
Collaborative & Analytics, Premier Inc.
704-816-5157
Mark_Hiller@PremierInc.com
Questions
Please attend
online session
evaluation